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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - april - june 2009

From the July 2, 2009 issue

  One of the most important ways to prevent medication errors is to learn about problems that have occurred in other organizations and to use that information to prevent similar problems at your practice site. To promote such a process, the following selected items from the April-June 2009 ISMP Medication Safety Alert! have been prepared for an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number to locate additional information as desired. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on the ISMP List of High-Alert Medications. The Action Agenda is also available for download in a Word format ( that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Many product-related problems can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

Shared MDIs: Can cross-contamination be avoided? (7)
Problem: As a cost-saving measure, some respiratory therapy departments have been using a single metered dose inhaler (MDI) canister to administer medication to multiple patients. Proponents cite significant cost savings, efficiency, and fewer treatment delays, while advocating that cross-contamination is unlikely if the nozzle is disinfected. Although studies have shown both positive and negative results regarding cross-contamination, opponents of the practice are not convinced that the benefits outweigh the risk.
Recommendation:  Carefully consider the risks and benefits if your facility is deciding whether to implement a common MDI protocol. If implemented, the Association for Professionals in Infection Control and Epidemiology (APIC) recommends carefully analyzing your processes to ensure handoffs between patients are not inadvertent sources of contact transmission, and emphasizing in the protocol the importance of hand hygiene and canister disinfection with alcohol after each use and prior to the next use.

v Intrathecal injection warrants mask worn by clinicians during procedure (12)
Problem: Two women who had just given birth to healthy babies developed bacterial meningitis following intrathecal injections of anesthesia by the same anesthesiologist. One mother died. Cultures identified Streptococcus salivarius, a common organism found in the mouth and respiratory tract, as the bacteria that caused the meningitis. The anesthesiology team did not routinely wear surgical masks during spinal procedures. Literature can be found in support of both wearing and not wearing a mask.  
Recommendation:  In 2005, the Centers for Disease Control and Prevention (CDC) commissioned a team to investigate prior episodes of post-myelography meningitis. Since then, the CDC recommends wearing a mask during all spinal injections. The decision to recommend a mask was based in large part on evidence that masks are effective in limiting the dispersal of oropharyngeal droplets and are recommended as an evidence-based practice for the placement of central venous catheters.  

Baxa Corporation compounder alert (7)
Problem: In March 2009, Baxa issued an Exacta-Mix 2400 Compounder Safety Alert to warn users that interacting with the touch-screen while the pump door is open may cause an inaccurate ingredient delivery. If the user presses the “RESUME” button at any time while the door is open and the compounder is pumping or alarming, an over-delivery of an individual ingredient will result. 
Recommendation: Communicate this information to all pharmacy personnel, and reinforce the need to close the pump door before pressing “RESUME.” Pharmacy staff who check bags after production should also check the MixCheck Report for any bubble or occlusion alarm, and ensure the proper steps were followed. A warning label for the compounder has also been provided by Baxa.

vFatal overdose of HYDROmorphone (11)
Problem: A 40-year-old opioid-naïve man died after receiving three IV injections of HYDROmorphone 2 mg in 9 hours. He was admitted to the hospital for throat pain from a strep infection. His wife mentioned that, previously, the patient had not tolerated VICODIN (acetaminophen and HYDROcodone).
Recommendation: Opioid-naïve patients should not receive high initial doses of opiates, especially HYDROmorphone;    2 mg IV is equivalent to approximately 12-14 mg of IV morphine. Always document the type of reaction the patient has experienced in response to a problem drug.

vMix-up between Hospira minibags of concentrated potassium chloride (8)
Problem: Potassium chloride 10 mEq in 100 mL (100 mEq/L) minibags were placed in an automated dispensing cabinet in a compartment intended for 10 mEq in 50 mL (200 mEq/L) minibags, which led to a mix-up. Both containers hold 10 mEq of potassium, but one is twice as concentrated as the other. The concentrations and volumes can be easily missed on the label. 
Recommendation: Separate the storage of these products in the pharmacy and patient care units. Use auxiliary stickers on the bags to make the concentration visible and to help differentiate the two concentrations. Consider stocking only one concentration of potassium chloride minibags.

vThird quarter 2008 QuarterWatchT shows frequently reported issues with baclofen (LIORESAL INTRATHECAL) (9)
ISMP’s QuarterWatch uncovered a large cluster of serious or fatal injuries associated with baclofen and an implantable pump used to deliver the drug into the cerebrospinal fluid. Medtronic Neuro-modulation issued an alert ( disclosure/product-advisories.html) because catheters delivering the drug to the spine were not being properly attached to the pump. This led to interruption of the drug and severe withdrawal symptoms.
Recommendation: Review the processes used to deliver Lioresal to uncover similar potential problems associated with connecting the catheter tubes to the pump and the adequacy of staff training to carry out this procedure. Establish written guidelines for pump use and Lioresal administration.

Third quarter 2008 QuarterWatchT shows ongoing issues with CHANTIX (varenicline) (9)
ISMP’s QuarterWatch found that Chantix accounts for more psychiatric side effects reported to the FDA than any other prescription medication. No action has been taken to provide a prominent warning about the drug’s potential to cause motor vehicle accidents through its effects on mood, memory, vision, and motor control. Little follow-up has occurred in response to reports of aggression, physical assaults, and homicidal thoughts.  
Recommendation: Alert prescribers to the risk profile of the drug and frequency of reports to FDA about these adverse effects. Educate patients who are admitted or discharged on Chantix about the risk profile of the drug and when to call the prescriber if they begin to experience these adverse effects.

vGreen caps on generic methylergonovine cause concern (12)
A newly approved generic methylergonovine maleate, packaged in a 1 mL vial, is available from PharmaForce. Unfortunately, the vial’s plastic cap is green and the very same shade as well-established PITOCIN (oxytocin) vials, available from JHP Pharma. Both drugs are found on obstetrical units; a mix-up would be disastrous.
Recommendation: We’ve contacted PharmaForce, and the company is looking into the possibility of changing the cap color. Until then, you may want to hold off on storing this generic product on obstetrical units.

ISMP launches first self assessment of ADC safety (12)
More than 80% of US hospitals have implemented automated dispensing cabinets (ADCs), making the evaluation of practices surrounding this technology an essential step in ensuring patient safety. To help assist organizations, ISMP has introduced a Medication Safety Self Assessment for ADCs.
Recommendation: The self assessment should be used by all hospitals that employ ADCs. The tool, along with instructions on how to use it, are available at:

Confusing nomenclature with valproic acid (4)
Valproic acid is available in various dosage forms and salts, so products can be confused. For example, a patient was supposed to receive DEPAKOTE ER (ordered as “divalproex ER”) but received divalproex “EC” (the enteric-coated form of divalproex). Another product, DEPAKENE, contains valproic acid when it is in capsule form and valproate sodium in liquid form. Valproate sodium is known as DEPACON in parenteral form.
Recommendation: Limit the forms of valproic acid available in the hospital, and educate staff about the different dosing schedules and indications for all formulations that remain. If possible, add a computerized alert to remind staff about the potential for mix-ups. When repeating back oral orders, use full words (e.g., extended release), not abbreviations. Separate storage and use auxiliary warning labels to differentiate the products.

Look-alike sound-alike (LASA) drug name list and ways to prevent mix-ups (10)
A March 2009 ISMP survey on LASA drug names showed that more than a quarter of nurses did not know whether their organization maintained a list of LASA drug names. Among hospitals that maintained such a list, many had no idea where the list originated, and more than half felt all the risk-reduction steps identified by their organizations had never been implemented. (For additional survey results, visit: acutecare/articles/20090521.asp)
Recommendation: All staff involved in medication use need to be aware of the organization’s list of LASA products, what it means, why it’s important to safety, and the steps to reduce mix-ups. Keep the list man-ageable. Implement strategies to prevent mix-ups with LASA products (see a table of risk-reduction steps in the newsletter). The LASA list should serve to draw special attention to a finite number of drugs that can cause harm if confused. The list should also promote knowledge of and compliance with drug-specific risk-reduction strategies.

On-Q pump issue (10)
The elastomeric On-Q pump is a device used after certain surgical procedures to slowly infuse local anesthetics into the incision area for pain control over a prolonged period. Use of this device has been associated with destruction of articular cartilage, which occurs most often in shoulders. The adverse effect happens when the medication has been infused directly into the shoulder joint rather than into the tissue around the shoulder.
Recommendation: Patients’ On-Q pump infusions should never be placed directly into the shoulder joint; if used for shoulder surgery, placement should be external to the joint cavity. While there are no data or evidence that the same effects occur in other joints (e.g., knee, hip), it may be reasonable to assume similar physiology and possible risk. Thus, it would be reasonable to avoid placing the On-Q catheter directly into any joint.

vFluorouracil antidote on the horizon (10)
Emergency use of an investigational drug, vistonuridine, is showing promise for reducing potentially fatal side effects of fluorouracil overdose. All 17 of the vistonuridine-treated patients recovered while 11 of 13 untreated patients died from overdoses. Because no antidote for fluorouracil is approved today, the manufacturer, Wellstat Therapeutics, has been responding to emergency requests for vistonuridine.
Recommendation: Ensure that all professional staff who provide care to oncology patients are aware of this antidote, and establish a guideline regarding how to get the drug for emergency use in the event of a fluorouracil overdose.

ZOSYN (piperacillin and tazobactam) should not be available in ADC stock (12)
A hospital began stocking Zosyn in the emergency department (ED) automated dispensing cabinet (ADC) so doses could be started quickly. To avoid problems, the ADC was programmed to query about penicillin allergies before the drug could be removed. This did not prevent the administration of Zosyn to a penicillin allergic patient within a few weeks of stocking the drug in the ED.
Recommendation: Do not stock Zosyn in ADCs if pharmacy can prepare doses as prescribed and dispense them in a timely fashion (or require a pharmacist’s review before retrieval from an ADC). One option in the ED is to place drugs like Zosyn and selected high-alert medications in a profiled ADC, while other less hazardous or less error-prone medications can remain in a non-profiled ADC.

Documenting a true allergy or other adverse symptoms (11)
An elderly patient for whom codeine was listed as an “allergy”—when it really only made him sleepy—received DARVOCET-N (propoxyphene napsylate,  acetaminophen) postoperatively while also taking carbamazepine. The patient died 2 days later from carbamazepine poisoning. Propoxyphene may decrease the metabolism of carbamazepine, there-by increasing the serum concentration of the drug.
Recommendation: Health professionals should communicate the symptoms experienced by a patient with a problem drug to avoid withholding a critical medication to which the patient has experienced a non-life-threatening drug reaction. Forms should prompt for this information. Some computers offer  pull-down menus from which to select the most appropriate reason for listing the problematic drug.  

LOVAZA (omega-3-acid ethyl esters) melts through foam cup   (8)
A nurse punched holes in a Lovaza gelatin capsule and squeezed the contents into a disposable foam plastic cup, then noticed that the bottom of the cup dissolved within 10 minutes. No warnings appear in the product labeling. The same problem is associated with nonprescription omega-3 products. The effect upon plastic oral syringes and toxicity from dissolved plasticizers is unknown. 
Recommendation: Place Lovaza and other omega-3 products on your facility’s “do not crush” list. (If you use ISMP’s “do not crush” list, be sure you have the most updated copy, available at: When these drugs are prescribed, add specific warnings to the medication administration records. 

Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

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